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The surgical management of chronic subdural hematoma

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An Erratum to this article was published on 03 July 2015

Abstract

Chronic subdural hematoma (cSDH) is an increasingly common neurological disease process. Despite the wide prevalence of cSDH, there remains a lack of consensus regarding numerous aspects of its clinical management. We provide an overview of the epidemiology and pathophysiology of cSDH and discuss several controversial management issues, including the timing of post-operative resumption of anticoagulant medications, the effectiveness of anti-epileptic prophylaxis, protocols for mobilization following evacuation of cSDH, as well as the comparative effectiveness of the various techniques of surgical evacuation. A PubMed search was carried out through October 19, 2010 using the following keywords: “subdural hematoma”, “craniotomy”, “burr-hole”, “management”, “anticoagulation”, “seizure prophylaxis”, “antiplatelet”, “mobilization”, and “surgical evacuation”, alone and in combination. Relevant articles were identified and back-referenced to yield additional papers. A meta-analysis was then performed comparing the efficacy and complications associated with the various methods of cSDH evacuation. There is general agreement that significant coagulopathy should be reversed expeditiously in patients presenting with cSDH. Although protocols for gradual resumption of anti-coagulation for prophylaxis of venous thrombosis may be derived from guidelines for other neurosurgical procedures, further prospective study is necessary to determine the optimal time to restart full-dose anti-coagulation in the setting of recently drained cSDH. There is also conflicting evidence to support seizure prophylaxis in patients with cSDH, although the existing literature supports prophylaxis in patients who are at a higher risk for seizures. The published data regarding surgical technique for cSDH supports primary twist drill craniostomy (TDC) drainage at the bedside for patients who are high-risk surgical candidates with non-septated cSDH and craniotomy as a first-line evacuation technique for cSDH with significant membranes. Larger prospective studies addressing these aspects of cSDH management are necessary to establish definitive recommendations.

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Authors and Affiliations

  1. Department of Neurological Surgery, Columbia University, College of Physicians & Surgeons, 710 West 168th Street, New York, NY, 10032, USA

    Andrew F. Ducruet, Bartosz T. Grobelny, Brad E. Zacharia, Zachary L. Hickman, Peter L. DeRosa, Kristen Anderson, Eric Sussman, Austin Carpenter & E. Sander Connolly Jr.

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  1. Andrew F. Ducruet
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  2. Bartosz T. Grobelny
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Correspondence to Andrew F. Ducruet.

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Christoph Woernle, Zurich, Switzerland

The authors reviewed and carefully analyzed the literature on treatment of chronic subdural hematoma. Looking back on history, Ambroise Pare, a French surgeon first described a subdural hemorrhage in 1559. Rudolf Virchow defined this disease in 1857 as pachymeningitis hemorrhagica interna. As the authors have nicely illustrated in this review, it is still considered one of the major issues in neurosurgery. Demographic changes will emphasize this in the future, demanding further evidence-based data on treatment modalities, but also on patients' outcome. Therefore, initiatives for multicenter, prospective, randomized trials to further evaluate the appropriate handling of patients with chronic subdural hematoma, need to be established.

An erratum to this article is available at http://dx.doi.org/10.1007/s10143-015-0644-0.

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Ducruet, A.F., Grobelny, B.T., Zacharia, B.E. et al. The surgical management of chronic subdural hematoma. Neurosurg Rev 35, 155–169 (2012). https://doi.org/10.1007/s10143-011-0349-y

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  • DOI: https://doi.org/10.1007/s10143-011-0349-y

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